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Updated: Apr 2 2023

Halo Orthosis Immobilization


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Images zones showing nerves_moved.jpg 3_moved.jpg
  • Introduction
    • Fixes skull relative to torso
      • provides most rigid form of cervical spine external immobilization
      • ideal for upper C-spine injury
    • Allows intercalated paradoxical motion in the subaxial cervical spine
      • therefore not ideal for lower cervical spine injuries (lateral bending least controlled)
        • "snaking phenomenon"
          • recumbent lateral radiograph shows focal kyphosis in midcervical spine
          • yet, upright lateral radiograph shows maintained lordosis in midcervical spine
  • Indications
    • Adult
      • definitive treatment of cervical spine trauma including
        • occipital condyle fx
        • occipitocervical dislocation
        • stable Type II atlas fx (stable Jefferson fx)
        • type II odontoid fractures in young patients
        • type II and IIA hangman’s fractures
      • adjunctive postoperative stabilization following cervical spine surgery
    • Pediatric
      • definitive treatment for
        • atlanto-occipital dissociation
        • Jefferson fractures (burst fracture of C1)
        • atlas fractures
        • unstable odontoid fractures
        • persistent atlanto-axial rotatory subluxation
        • C1-C2 dissociations
        • subaxial cervical spine trauma
      • preoperative reduction in the patients with spinal deformity
  • Contraindications
    • Absolute
      • cranial fractures
      • infection
      • severe soft-tissue injury
        • especially near proposed pin sites
    • Relative
      • polytrauma
      • severe chest trauma
      • barrel-shaped chest
      • obesity
      • advanced age
        • recent evidence demonstrates an unacceptably high mortality rate in patients aged 79 years and older (21%)
  • Imaging
    • CT scan prior to halo application
      • indications
        • clinical suspicion for cranial fracture
        • children younger than 10 to determine thickness of bone
  • Adult Technique
    • Adults
      • torque
        • tighten to 8 inch-pounds of torque
      • location
        • total of 4 pins
        • 2 anterior pins
          • safe zone is a 1 cm region just above the lateral one third of the orbit (eyebrow) at or below the equator of the skull
            • this is anterior and medial to temporalis fossa/temporalis muscle
            • this is lateral to supraorbital nerve
        • 2 posterior pins
          • placed on opposite side of ring from anterior pins
      • followup care
        • can have patient return on day 2 to tighten again
        • proper pin and halo care can be done to minimize chance of infection
  • Pediatric Technique
    • Pediatrics
      • torque
        • best construct involves more pins with less torque
          • total of 6-8 pins
          • lower torque (2-4 in-lbs or "finger-tight")
      • pin locations
        • place anterior pins lateral enough to avoid injury to the frontal sinus, supratrochlear and supraorbital nerves
        • place pins anterior enough to avoid the temporalis muscle
        • place pins posteriorly opposite from anterior pins
      • brace/vest
        • custom fitted vest for children > 2 years
        • children <2 yrs should use Minerva cast
      • CT scans may help in pin placement
        • can help facilitate avoiding cranial sutures
        • can help facilitate avoiding thin regions of skull
        • help limit risk of complications
  • Complications
    • Higher complications in children (70%) than adults (35%)
    • Loosening (36%)
      • can be treated with retightening
      • if continues to loosen, should be treated with pin exchange
    • Infection (20%)
      • can especially occur with posterior pin in temporalis fossa because
        • pins hidden in hairline
        • bone is thin
        • temporalis muscle moves with chewing
      • can be treated with oral antibiotics if pin not loose
        • if pin infection and loose then pin should be removed
    • Discomfort (18%)
      • treated by loosening skin around pin
    • Dural puncture (1%)
    • Abducens nerve (Cranial Nerve VI) palsy
      • epidemiology
        • is most commonly injured cranial nerve with halo
      • pathophysiology
        • thought to be a traction injury to cranial nerve 6, which affects abducens nerve (innervate lateral rectus muscles)
      • symptoms
        • diplopia
      • physical exam
        • loss of lateral gaze on affected side
      • treatment
        • observation as most resolve spontaneously
    • Supraorbital nerve palsy
      • injured by medially placed anterior pins
    • Supratrochlear nerve palsy
      • injured by medially placed anterior pins
    • Medical complications
      • pneumonia
      • ARDS
      • arrhythmia
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